Guidelines for Training in Diagnostic and Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP)

DISCLAIMER:

Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and to the variables at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question.

These guidelines are developed under the auspices of SAGES, the guidelines committee and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated.

I. TRAINING

Training in diagnostic and therapeutic ERCP should only be sought by individuals with interest and training in the treatment of hepatopancreaticobiliary disease.  Surgeons seeking training in ERCP should anticipate performing adequate numbers of procedures to maintain proficiency, and remain committed to advancing their skills in this continually evolving procedure.

Training for ERCP and advanced therapeutic procedures may be obtained during surgical residency, gastroenterology fellowships, advanced surgical endoscopy fellowships, hepatopancreaticobiliary fellowships, or during other advanced surgery fellowships and preceptorships dedicated to providing a rich educational experience in diagnostic and therapeutic ERCP.

The training program must include practical and didactic instruction regarding 1) instruments and accessories, 2) indications and contraindications, 3) diagnostic and therapeutic techniques, 4) appropriate use of conscious sedation, 5) complications and their management, and 6) short-term and long-term outcomes. The program must include adequate direct experience to allow the surgeon to successfully complete a majority of diagnostic and therapeutic procedures in a reasonable amount of time.  All enrollees in ERCP training programs should gain proficiency in both diagnostic and therapeutic procedures, as there is no role for the performance of “diagnostic only” ERCP.  While not essential, an introduction to endoscopic ultrasound is valuable during training in ERCP, since there is substantial overlap of these techniques in caring for patients with biliary and pancreatic diseases.

While performing an arbitrary number of procedures does not define proficiency, completion of a significant volume of both diagnostic and therapeutic ERCP’s under the supervision of a qualified endoscopic instructor is necessary to achieve acceptable rates of selective cannulation.

II. SHORT COURSES

Short courses with “hands-on” experience using computer simulators or animal models for ERCP do not constitute sufficient training for privileging in these procedures. However, these courses may provide orientation to diagnostic and therapeutic ERCP techniques, and provide the clinician an opportunity to practice specific skills and gain familiarity with necessary equipment and accessories. Short courses may benefit surgeons already trained in ERCP who seek to hone their skills or gain exposure to additional adjunctive treatments.

III. COMPETENCE

Proficiency in diagnostic and therapeutic ERCP is defined as the ability to: 1) reliably achieve selective cannulation of the desired duct; 2) perform a controlled sphincterotomy; 3) achieve biliary and/or pancreatic decompression; and 4) gather sufficient endoscopic, radiographic, and pathologic material to formulate an accurate diagnosis and efficient treatment plan.  Proficiency in ERCP should also include mastery of commonly related therapeutic maneuvers such as stone clearance, stent placement, and management of sphincterotomy-related hemorrhage.  Proficiency in advanced therapeutic skills such as stricture dilation, precut sphincterotomy, metallic endoprosthesis placement, and biliary manometry should be based on an appropriate individual experience.  Additional training may be necessary to master these and other advanced skills.  Utilizing current quality improvement mechanisms should assess clinical outcomes.

IV. GRANTING OF CLINICAL PRIVILEGES

The granting of privileges is the responsibility of each hospital and should be based on uniform standards applied to all practitioners applying for similar privileges, in all settings where endoscopy is performed.  A decision to grant ERCP privileges should be based in large part on the recommendation of the applicant’s endoscopic instructor verifying proficiency in the cognitive, diagnostic, and therapeutic aspects of ERCP.  Proctoring by another qualified member of the medical staff may be helpful in assuring proficiency in the performance of ERCP prior to a decision to grant or continue privileges for the applicant.

V. MAINTENANCE OF SKILLS

Each physician is responsible for maintaining proficiency in ERCP once initial privileges are granted, and hospitals should assess the endoscopists performance through ongoing quality improvement initiatives.  The maintenance of skills in diagnostic and therapeutic ERCP depends not only on the performance of adequate numbers of procedures with adequate frequency, but also on continuing medical education and adoption of new adjunctive therapies as this advanced procedure evolves.

VI. REFERENCES: 

1. Training surgeons in endoscopic retrograde cholangiopancreatography. Vitale GC, Zavaleta CM, Vitale DS, Binford JC, Tran TC, Larson GM.  Surg Endosc 2006 Jan;20(1):149-152.
2. Adverse outcomes of endoscopic retrograde cholangiopancreatography. Freeman ML. Rev Gastroenterol Disord  2002 Fall;2(4):147-68.
3. ERCP training and experience.Waye JD, Bornman PC, Chopita N, Costamagna G, Ganc AJ, Speer T. Gastrointest Endosc 2002 Oct;56(4):607-8.
4. ERCP outcomes: defining the operators, experience, and environments. Petersen BT. Gastrointest Endosc 2002 Jun;55(7):953-8.
5. NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consensus State Sci Statements 2002 Jan 14-16; 19(1): 1-26.
6. The Erlangen Endo-Trainer: life-like simulation for diagnostic and interventional endoscopic retrograde cholangiography. Neumann M, Mayer G, Ell C, Felzmann T, Reingruber B, Horbach T, Hohenberger W. Endoscopy  2000 Nov;32(11):906-10.
7. Endoscopic retrograde cholangiopancreatography: toward a better understanding of competence. Jowell PS. Endoscopy  1999 Nov;31(9):755-7.
8. Endoscopic retrograde cholangiopancreatography in a general surgery training program.  Meguid A; Scheeres DE; Mellinger JD; Am Surg 1998 Jul;64(7):622-5; discussion 625-6.
9. ERCP: A review of technical competency and workload in a small unit.  Schlup MM; Williams SM; Barbezat GO; Gastrointest Endosc 1997 Jul;46(1):48-52.
10. Assessment of technical competence during ERCP training.  Watkins JL; Etzkorn KP; Wiley TE; DeGuzman L; Harig JM; Gastrointest Endosc 1996 Oct;44(4):411-5.
11. Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography.  Jowell PS; Baillie J; Branch MS; Affronti J; Browning CL; Bute BP; Ann Intern Med 1996 Dec 15;125(12):983-9.